Episode 18: The Ventilator Part 2

Vent 2

Many apologies for the delay in the release of this podcast!

A second apology is due for the sound quality – it was recorded at a ‘live’ HEMS base – this has led to lots of background noise I am afraid. We have done our best to edit this out / reduce its effect but I’m afraid we are not experts in this area!

This podcast is part 2 of this series on the ventilator – and you should be familiar with the first in this series before progressing further!

Others have written excellent summaries of the themes of this podcast – please follow the links below:

In summary:

  • PEEP is important – you need to understand its benefits and potential harms.
  • If the patient is requiring more oxygen than you would expect try increasing the PEEP.
  • You really, really need to know your kit. Know what your ventilator can and can’t do –  know how it works and how its alarms work.

 

Episode 17: Broken? Impact on the rescuer

Broken...

This episode has been compiled over a year – many thanks to our four contributors, who have shared their stories and knowledge. They were interviewed at TraumaCare 2016, TraumaCare 2017 and the BASICS/FPHC Conference 2016.

If you ever need to talk about the impact of stresses and work experiences on you, please find a friend, colleague, GP, work Occupational Health Service, or one of the charities listed below.


Tony’s article describing his experience of providing medical care to those involved in the Shoreham air crash:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4758481/


Links to some of the resources Matt mentioned:

Mind Blue Light Campaign:

0j6q5p5Y

http://www.mind.org.uk/news-campaigns/campaigns/bluelight/

Watch this excerpt from the West Wing:

If you would like to check your own resilience score, you could use this tool recommended by Matt:

https://www.robertsoncooper.com/iresilience/

http://www.marchonstress.com

http://www.theredpoppycompany.co.uk


More information from Rusty’s interview:

MaslowsHierarchyOfNeeds.svg

By FireflySixtySeven using Inkscape, from Maslow’s A Theory of Human Motivation.

Want to know more about EMDR?

http://emdrassociation.org.uk/what-is-emdr/background-and-basics/

Rusty recommended The Howl – EMS Wolfpack podcasts for more on this subject:

https://itunes.apple.com/gb/podcast/the-howl/id1073333491?mt=2&i=364170004


This is the article written by fire fighter Rob Norman

https://www.theguardian.com/public-leaders-network/2016/jan/30/mental-health-dead-people-flashbacks-emergency-services-fireighters

Episode 16: “Blood”

blood

 

There is the potential for significant controversy in this month’s episode – and we would really appreciate the feedback of the prehospital community on this one.

We have held the ‘no clear fluids’ mantra close to our hearts for most of our prehospital careers. We ‘know’ that giving sea water to our patients, and diluting all of blood’s ‘good bits’ can’t be healthy. We believed in permissive hypotension – we were probably wrong.

Priorities for the bleeding trauma patient must include:

  • Minimum time to control of bleeding (tourniquets / haemostatics / knife / interventional radiology)
  • Normothermia
  • Appropriate choice of destination (knife / IR)
  • ? Early correction of hypotension (especially if blunt trauma / associated head injury)

The balances of harms in the context of blunt trauma between the negative effects of infusing saline versus the negative effects of hypotension are unknown and prehospital actions need to be customised to an individual patient and situation.

In systems in which a potentially less harmful resuscitation strategy can be delivered sooner – PH systems with packed red cells / fresh frozen plasma / whole blood or freeze dried plasma, then it seems pragmatic to aim for normotension (predicted normal blood pressure) sooner in the patient’s care timeline than we have been e.g. at one hour. In patients with penetrating trauma permissive hypotension may remain useful for longer or at least until a patient can be differentiated and the bleeding controlled.

Lots to think about!

 

References:

RePhill Trial Homepage: http://www.birmingham.ac.uk/research/activity/mds/trials/bctu/trials/portfolio-v/Rephill/index.aspx

  1. Smith IM, James RH, Dretzke J, Midwinter MJ. Prehospital Blood Product Resuscitation for Trauma. Shock. 2016 Jul;46(1):3–16.
  2. Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients. Powell EK, Hinckley WR, Gottula A, Hart KW, Lindsell CJ, McMullan JT. J Trauma Acute Care Surg. 2016 Sep;81(3):458-62.
  3. Penn-Barwell JG, Roberts SA, Midwinter MJ, Bishop JR: Improved survival in UK combat casualties from Iraq and Afghanistan: 2003-2012. J Trauma Acute Care Surg 78(5):1014–1020, 2015.
  4. Holcomb JB, Donathan DP, Cotton BA, Del Junco DJ, Brown G, Wenckstern TV, Podbielski JM, Camp EA, Hobbs R, Bai Y, et al.: Prehospital transfusion of plasma and red blood cells in trauma patients. Prehosp Emerg Care 19(1):1–9, 2015.
  5. Weaver AE, Eshelby S, Norton J, Lockey DJ: The introduction of on-scene blood transfusion in a civilian physician-led pre-hospital trauma service. Scand J Trauma Resusc Emerg Med 21(Suppl1):S27, 2013.
  6. Bodnar D, Rashford S, Williams S, Enraght-Moony E, Parker L, Clarke B: The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells. Emerg Med J 31(2):93–95, 2014.

Episode 15: Paediatric Trauma & How to Do Sim

paed-sim

Paediatric Trauma

TARN report: Severe Injury in Children

Simulation

ATACC:The Anaesthesia Trauma and Critical Care course

Thanks to Mark Forrest (@ObiDoc) for sharing these videos:

References

  1. Spurr J, Gatward J, Joshi N, Carley SD. Top 10 (+1) tips to get started with in situ simulation in emergency and critical care departments. EMJ. 2016.
  2. Bredmose PP, Habig K, Davies G, Grier G, Lockey D. Scenario based outdoor simulation in pre-hospital trauma care using a simple mannequin model. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2010.
  3. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Quality & Safety. 2013; 22: 468-477.
  4. Boet S, Bould MD, Layat Burn C, Reeves S. Twelve tips for a successful interprofessional team-based high-fidelity simulation educational session. Medical Teacher. 2014; 36: 853-857.

Episode 14: Thoracotomy

thoracotomy

 

Details of the surgical skills course mentioned in the podcast can be found here:

https://wmstc.co.uk/portfolio/phem-ess/

The Sydney HEMS Traumatic Cardiac arrest operating procedure can be viewed on their website, and there are a number of useful references within the document:

Policies and Procedures

An excellent ‘how to do it’ paper, published in 2005, by the London HEMS team, can be accessed via the link below:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726527/pdf/v022p00022.pdf

 

Equipment required for resuscitative thoracotomy:equipment-required-for-thoracotomy

Surface anatomy:

surface-anatomy-for-thoracotomy

Appearance of pericardial clot

pericardial-clot

A foley catheter being used to fill a cardiac wound – note how easily this could be pulled out.

foley-catheter-in-cardiac-wound

An open chest with aortic compression

open-chest-with-aortic-compression

Simulation of resuscitative thoracotomy by London HEMS team.

For an entertaining and insightful discussion about the impact of undertaking thoracotomy, listen to Dr John Hinds talk from SMACC 2015. Highly recommended.

http://intensivecarenetwork.com/hinds-crack-the-chest-get-crucified/

And for a summary of the evidence and recommendations, have a look at the St Emlyns blog:

http://stemlynsblog.org/jc-east-lets-be-blunt-about-ed-thoracotomy/

References

  • Smith JE, Rikard A, Wise D. Traumatic Cardiac Arrest. Journal of the Royal Society of Medicine 2015. 108(1): 11-16.
  • Wise et al. Emergency thoracotomy: “how to do it”. EMJ; 2005: 22-24.
  • Hunt et al. Emergency thoracotomy in thoracic trauma: a review. Injury; 2006 (37): 1-19.
  • Clay et al. Emergency Department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World Journal of Emergency Surgery; 2006: 1:4.
  • Rhee et al. Survival after Emergency Department thoracotomy: review of published data for last 25 years. J Am Coll Surg; 2000. 190(3): 288-298
  • ACS Committee on Trauma Working Group. Practice Management guidelines for ED Thoracotomy. J Am Coll Surg. 2001, 193 (3): 303-309.
  • Editorial. When should we stop resuscitative efforts after blunt traumatic arrest. Injury; 2008 (39): 967-969.
  • Joint Position Statement of Nat Assoc EMS Physicians and ACS Committee on Trauma. Guidelines for withholding or termination of resuscitation in prehospital cardiopulmonary arrest. J Am Coll Surg; 2003 (1): 106-111.
  • Tarney et al.Outcomes following military traumatic cardiorespiratory arrest: A prospective observational study. Resuscitation; 2011: 1194-1197

Episode 13: The Ventilator

ventilation

Ventilation – a dark art. Difficult to be a master, easy to be average (or terrible)!

This is “part 1”, which includes some of the basic (and not very basic) concepts behind ventilation.

We recorded over 60 minutes of excellent content with George – we will post more below as soon as it is edited. .

Check out Georges powerpoint – its excellent!

introduction-to-mechanical-ventilation-11nov2016-podcast

Episode 12: Breaking Bad News

breaking-bad-news

YouTube videos:

From the police officer’s perspective: https://www.youtube.com/watch?v=toaA_TNwcxg

From the mother’s perspective: https://www.youtube.com/watch?v=0KJZXOKStao

The paper about watching resuscitation is this one:

http://www.nejm.org/doi/full/10.1056/NEJMoa1203366#t=article

This is a section taken from the London Ambulance Service clinical bulletin, from 2011, which includes the SPIKES mnemonic:

las-breaking-bad-news-guidance

The alternative mnemonic mentioned in the podcast is GRIEV_ING, which has been developed for use in the ED.

griev_ing-mnemonic

References

Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. Spikes – a six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist. 2000; 5: 302-311.

Hobgood C, Harward D, Newton K, Davis W. The educational intervention “GRIEV_ING” improves the death notification skills of residents. Journal of Academic Emergency Medicine. 2005; 12: 296-301.

Jabre P, Belpomme V, Azoulay E et al. Fanily presence during cardiopulmonary resuscitation. The New England Journal of Medicine. 2013: 368 (11): 1008-1018.

Episode 11: Gentle Patient Handling

Gentle Patient Handling

 

The paper we mentioned by Jonathan Benger and Jules Blackham can be accessed here:

https://sjtrem.biomedcentral.com/articles/10.1186/1757-7241-17-44

Stable versus unstable spinal injury

The location of an injury and involvement of different structures defines the stability of a spinal injury.

Screen Shot 2016-07-14 at 12.02.03

Anterior column: anterior longitudinal ligament and the anterior half of the vertebral body/disc.

Middle column: posterior half of the vertebral body/disc and the posterior longitudinal ligament.

Posterior column: facet joints, ligamentum flavum, the spinous processes and the interconnecting ligaments.

An injury involving only the anterior column is considered to be stable, as will an isolated fracture of a spinous or transverse process. An unstable injury is one which involves all 3 columns and often one in which 2 columns are disrupted.

Screen Shot 2016-07-14 at 12.20.03

References

  1. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003 Dec 25;349(26):2510–8.
  2. Oteir AO, Smith K, Stoelwinder JU, Middleton J, Jennings PA. Should suspected cervical spinal cord injury be immobilised?: A systematic review. Injury. Elsevier Ltd; 2015 Apr 1;46(4):528–35.
  3. Smyth M, Cooke MW. Value of a rigid collar: in need of more research and better devices. Emergency Medicine Journal. 2013 May 13;30(6):516–6.
  4. Crane T, Cooke MW, Wellings R, Wayte S, Higgins J. MRI study of effectiveness of cervical spine immobilisation- a pilot study. The University of Warwick. 2007 Aug 1;:1–18.
  5. BOAST2: SPINAL CLEARANCE IN THE TRAUMA PATIENT. British Orthopaedic Association Standards for Trauma (BOAST); 2008. 1 p.
  6. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 2008 Apr 15;5(3):214–9.
  7. Prasarn ML, Horodyski M, Dubose D, Small J, Del Rossi G, Zhou H, et al. Total Motion Generated in the Unstable Cervical Spine During Management of the Typical Trauma Patient. Spine. 2012 May;37(11):937–42.
  8. Gill DS, Mitra B, Reeves F, Cameron PA, Fitzgerald M, Liew S, et al. Can initial clinical assessment exclude thoracolumbar vertebral injury? Emergency Medicine Journal. 2013 Jul 19;30(8):679–82.
  9. Leech C, Porter K, Bosanko C. Log-rolling a blunt major trauma patient is inappropriate in the primary survey. Emergency Medicine Journal. 2013 Dec 22;31(1):86–6.
  10. Horodyski M, Conrad BP, Del Rossi G, DiPaola CP, Rechtine GR II. Removing a Patient From the Spine Board: Is the Lift and Slide Safer Than the Log Roll? J Trauma. 2011 May;70(5):1282–5.
  11. I J, A M, Yu E, Tulman D, Jones C, Stawicki S. A systematic review of the need for MRI for the clearance of cervical spine injury in obtunded blunt trauma patients afternormal cervical spine CT. Journal of Emergencies, Trauma, and Shock. 2014 Feb 11;7(4):251–5.
  12. Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review. J Neurotrauma. 2014 Mar 15;31(6):531–40.
  13. Armstrong BP, Simpson HK, Crouch R, Deakin CD. Prehospital clearance of the cervical spine: does it need to be a pain in the neck? Emerg Med J. 2007 Jul 1;24(7):501–3.
  14. PhD JRE, PhD JWS, OTD TLS, MSOT JLE, EMTP JSSM, MD RSN. Selected Topics: Prehospital Care. J Emerg Med. Elsevier Ltd; 2013 Jan 1;44(1):122–7.
  15. Connor D, Greaves I, Porter K, Bloch M, consensus group Faculty of Pre-Hospital Care. Pre-hospital spinal immobilisation: an initial consensus statement. Emerg Med J. 2013 Dec 1;30(12):1067–9.
  16. Fattah S, Johnsen AS, Andersen JE, Vigerust T, Olsen T, Rehn M. Rapid extrication of entrapped victims in motor vehicle wreckage using a Norwegian chainmethod – cross-sectional and feasibility study. 2014 Jul 3;14(1):1–5.
  17. Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, et al. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ. 2008 Apr 22;178(9):1141–52.
  18. Edwards MA, Verwey J, Herbert S, Horne S, Smith JE. Cervical spine clearance in the elderly: do elderly patients get a bad deal? Emerg Med J. 2013 May 23.
  19. Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review. J Neurotrauma. 2014 Mar 15;31(6):531–40.
  20. Shafer JS, Naunheim RS. Cervical spine motion during extrication: a pilot study. West J Emerg Med. 2009 May;10(2):74–8.
  21. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries. J Trauma. 1993 Mar;34(3):342–6.
  22. Hale DF, Fitzpatrick CM, Doski JJ, Stewart RM, Mueller DL. Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger. Journal of Trauma and Acute Care Surgery. 2015 May;78(5):943–8.
  23. Benger J, Blackham J. Why do we put cervical collars on conscious trauma patients? Scand J Trauma Resusc Emerg Med. 2009;17(1):44.

Episode 10: Stress Inoculation

Inoculation training

Big thanks to Anand Swaminathan @EMSwami, Chris Nickson @precordialthump, Jesse Spurr @Inject_Orange, Chris Hicks @HumanFact0rz, and Tom Evens @doctomevens

Their pre-workshop reading/listening recommendations:

http://stemlynsblog.org/englishman-south-africa-robert-lloyd-st-emlyns/

http://emcrit.org/podcasts/toughness-michael-lauria-i/

IMG_6894

 

BandwidthIMG_6896

IMG_6892

 

Visualisation tips:

IMG_6895

 

Episode 9: Maternal Collapse

Mat collapse-2

Apologies for the quality of the sound – we recorded in a very echo-ey office!

The Royal College of Obstetricians and Gynaecologists (RCOG) green top guideline is accessible here:

https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_56.pdf

We have talked about ramping previously, in Episode 6: Oxygenation. This is how a pregnant patient should be positioned for airway manoeuvres and interventions, for example induction of anaesthesia and intubation.

Screen Shot 2016-03-17 at 10.09.34

The ILCOR 2015 update pertaining to Cardiac Arrest Associated with Pregnancy is accessible here:

https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-10-special-circumstances-of-resuscitation/

Including this picture demonstrating manual displacement of the uterus:Manual displacement

The concept of deliberate practice is discussed in more details on these sites:

This is Cliff Reid (resus.me) talking about his lecture from the Royal College of Emergency Medicine Conference in 2015:

http://resus.me/rcem15/

And this is Simon Carley’s (St Emlyn’s) blogpost on the subject:

http://stemlynsblog.org/the-pursuit-of-mastery-through-deliberate-practice/

And last, but not least, Scott Weingart (EMCRIT) from SMACC 2013

http://emcrit.org/podcasts/path-to-insanity/

 

References

Advanced Life Support (7th Edition). Resuscitation Council UK. 2016.

Parry R, Asmussen T, Smith JE. Perimortem caesarean section. EMJ. 2016; 33: 224-229.

Clark SL, Cotton DB, Pivarnik JM et al. Position change and central hemodynamic profile during normal third trimester pregnancy and post partum. Am J Obstetrics & Gynaecology. 1991; 164: 883-887.

Bamber JH, Dresner M. Aortocaval compression in pregnancy: the effect of changing the degree and direction of lateral tilt on maternal cardiac output. Anaesthesia & Analgesia. 2003; 97: 256-258.

Lee SWY, Khaw KS, Kee WN, Leung TY, Critchley LAH. Haemodynamic effects from aortocaval compression at different angles of lateral tilt in non-labouring term pregnant women. British Journal of Anaesthesia. 2012; 109: 950-956.

Episode 8: Chemical Suicide

Chemical Suicide

The recent resurgence in this method of suicide has put emergency responders at a significant increase of serious injury and death.

This podcast discussed the current most frequent methods of attempted and successful inhalational suicide  – keep safe.

 

 

There are a multitude of professional and advisory websites out there.

We are keen not to raise awareness of specific combinations of chemicals / products.

Episode 7: Sepsis

We hope you enjoyed our sepsis podcast. It is obviously a huge topic and there is lots of information to cover; a couple of other recently released podcasts are available which are produced with the Emergency Medicine community in mind, but will no doubt expand your knowledge.

 

St Emlyns Induction podcast on Sepsis. March 2016. A great summary of what to do when a patient with suspected sepsis first arrives in the ED.

And from our buddies at HEFT EM CAST:

http://www.heftemcast.co.uk/sepsis-in-the-ed/

A bit more detail covering some of the research in an easy to understand way. It particularly discussed the original Rivers trial which we mention in the podcast.

It’s worth remembering that sepsis is a spectrum of disease when assessing patients.

Slide1

It is worth noting, that with “Sepsis 3” many of these terms will become out-of-date – but validation work is required…

The Rivers’ paper can be accessed here: http://www.nejm.org/doi/full/10.1056/nejmoa010307

It was a single centre study which compared standard care with protocolised resuscitation packaged together as early goal-directed therapy (EGDT). This is what the study did:

rivers jpg

As you will see the trial was relatively small – with only 263 patients being recruited into the trial. What was impressive, and changed practice, forming the basis of the Surviving Sepsis Campaign, was the significant reduction in mortality. Patients in the standard care group had a mortality of 46% compared with the treatment group 30%, which was statistically significant (p=0.009).

Further large randomized controlled studies to try and demonstrate the same mortality benefit from Rivers-style EGDT have not shown the same results (Process, Arise, PROMISe). Patients in these trials were randomly assigned to one of two groups. The ‘intervention’ group received the new treatment, in this case EGDT, which was being tested. The ‘standard care’ group were looked after according to how the clinician would usually treat a patient with severe sepsis. This was the same principle as in the Rivers trial: the standard care group is the ‘control’ group against which changes in outcome for the ‘intervention’ group are compared. The mortality in both groups in all 3 trials was similar, there was not the significant reduction in mortality seen in the Rivers study. This was probably because, as we say in the podcast, ‘standard’ care for sepsis has improved considerably in the intervening years. The control group received many similar treatments as the ‘intervention’ group (just not full protocolised EGDT) highlighting that with good sepsis care (fluid resuscitation, close monitoring, early appropriate antibiotic administration), mortality can be reduced.

Red flag sepsis is a way of identifying those patients with sepsis who are high risk  and who warrant immediate treatment:

red flag

Have a look at the UK Sepsis Trust website: http://sepsistrust.org. There are toolkits available to download, including one specifically written for the prehospital environment with the College of Paramedics, which summarises the recognition and management of sepsis.

 Link to the Sepsis-3 guideline. 

Reviewed (again for the Emergency Medicine community) here.

When Tim talks about test characteristics he is referring to the ability of a test to correctly identify the presence or absence of an illness. Some may think that if a test is positive it always means the patient has the illness, or indeed if it is negative it rules out the possibility of that illness but this is not the case with many of the tests we use.

Think about ECG as an example,test So, where the box is green, the test has given us the correct result for the patient. But, where the box is red the test has given us the incorrect result: you will all be able to think about patients in whom the ECG was normal, but the patient turned out to have had an MI, or when the ECG showed an MI but the patient turned out not to have had one. These tables are used when assessing the usefulness of a test (or it’s sensitivity and specificity), and, when researching how useful tests are we need the majority of patients to fall into the green boxes.

We will put together a podcast on test characteristics over the next couple of months, which will explain this in more detail. An amazing podcast on the subject can be found at SMART EM: SMART Testing: Back to Basics

As always, any feedback, comments etc. – please let us know on the blog below!

  1. Herlitz J, ng AB, m BW-S, Axelsson C, Bremer A, Hagiwara M, et al. Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care. Scand J Trauma Resusc Emerg Med. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine; 2012 Jun 27;20(1):1–1.
  2. Studnek JR, Artho MR, Garner CL, Jones AE. The impact of emergency medical services on the ED care of severe sepsis. Am J Emerg Med. 2012 Jan;30(1):51–6.
  3. Puskarich MA, Marchick MR, Kline JA, Steuerwald MT, Jones AE. One year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study. Crit Care. 2009;13(5):R167.
  4. Seymour CW, Rea TD, Kahn JM, Walkey AJ, Yealy DM, Angus DC. Severe Sepsis in Pre-Hospital Emergency Care. Am J Respir Crit Care Med. 2012 Dec 15;186(12):1264–71.
  5. Band RA, Gaieski DF, Hylton JH, Shofer FS, Goyal M, Meisel ZF. Arriving by Emergency Medical Services Improves Time to Treatment Endpoints for Patients With Severe Sepsis or Septic Shock. Academic Emergency Medicine. 2011 Aug 30;18(9):934–40.
  6. Seymour CW, Cooke CR, Heckbert SR, Spertus JA, Callaway CW, Martin-Gill C, et al. Prehospital intravenous access and fluid resuscitation in severe sepsis: an observational cohort study. 2014 Oct 28;:1–9.
  7. Trust US. You Gov Poll – Public Awareness of Sepsis. UK Sepsis Trust; 2014 Nov pp. 1–1.
  8. MD GEH, MD RET, MD RS, MD JDL, BS AMB, BS AJS, et al. ACCEPTED MANUSCRIPT. Am J Emerg Med. Elsevier B.V; 2015 Aug 26;:1–31.
  9. Amado Alejandro Baez MD MSc MFFF, MD LC. ACCEPTED MANUSCRIPT. Am J Emerg Med. Elsevier B.V; 2015 Oct 17;:1–16.
  10. Guerra WF, Mayfield TR, Meyers MS, Clouatre AE, Riccio JC. Early detection and treatment of patients with severe sepsis by prehospital personnel. J Emerg Med. 2013 Jun;44(6):1116–25.
  11. Gaieski DF, Mikkelsen ME, Band RA, Pines JM, Massone R, Furia FF, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department*. Crit Care Med. 2010 Apr;38(4):1045–53.
  12. Yealy DM, Huang DT, Delaney A, Knight M, Randolph AG, Daniels R, et al. Recognizing and managing sepsis: what needs to be done? ??? ??? 2015 Apr 24;:1–10.
  13. Báez AA, Hanudel P, Perez MT, Giráldez EM, Wilcox SR. Prehospital Sepsis Project (PSP): knowledge and attitudes of United States advanced out-of-hospital care providers. Prehosp Disaster Med. 2013 Apr;28(2):104–6.
  14. Harnden A. Parenteral penicillin for children with meningococcal disease before hospital admission: case-control study. BMJ. 2006 Jun 3;332(7553):1295–8.
  15. Femling J, Weiss S, Hauswald E. EMS Patients and Walk-In Patients Presenting With Severe Sepsis: Differences in Management and Outcome. South Med J. 2014.
  16. Gray A, Ward K, Lees F, Dewar C, Dickie S, McGuffie C, et al. The epidemiology of adults with severe sepsis and septic shock in Scottish emergency departments. Emergency Medicine Journal. 2013 Apr 12;30(5):397–401.
  17. Seymour CW, Cooke CR, Mikkelsen ME, Hylton J, Rea TD, Goss CH, et al. Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department. Prehosp Emerg Care. 2010 Apr;14(2):145–52.
  18. Hahné SJM, Charlett A, Purcell B, Samuelsson S, Camaroni I, Ehrhard I, et al. Effectiveness of antibiotics given before admission in reducing mortality from meningococcal disease: systematic review. BMJ. 2006 Jun 3;332(7553):1299–303.
  19. Wang HE, Weaver MD, Shapiro NI, Yealy DM. Opportunities for Emergency Medical Services care of sepsis. Resuscitation. 2010 Feb;81(2):193–7

 

How to cite this podcast:

Nutbeam T, Bosanko C. Sepsis. PHEMCAST. 2016 [cite Date Accessed]. Available from: http://www.phemcast.co.uk

Episode 6: Oxygenation

Oxygenation

To provide a bit of balance following our earlier hyperoxia podcast, this episode we are discussing circumstances when we want to deliver extra oxygen to patients and ways to do this effectively, including an interview with Sydney HEMS Consultant Yash Wilmalasena on apnoeic oxygenation. Hope you find it useful!

 

Some of the stuff we talked about:

Optimal patient positioning when managing the airway and assisting ventilation has traditionally been taught as ‘sniffing the morning air’, shown here.Screen Shot 2016-03-17 at 09.28.46

But now, learning from bariatric practice we are realising that ramping is better for airway optimisation. In this position the patient’s tragus is lined up with their sternal notch to make the airway as straight as possible.

Screen Shot 2016-03-17 at 10.09.34Taken from: http://www.emsworld.com/article/11264318/airway-management-and-ventilation-best-practices

A water’s circuit looks like this:

Labelled waters circuit

This is an image of the oxygenation dissociation curve mentioned in the podcast. Taken from Weingart & Levitan 2012.Screen Shot 2016-03-17 at 10.14.50

Here are some other great resources which demonstrate some of the principles we have discussed:

Our Birmingham Emergency Medicine colleagues review the evidence so far for apnoeic oxygenation:

http://www.heftemcast.co.uk/apnoeic-oxygenation/

There are some short videos from Scott Weingart demonstrating some of the techniques discussed available here:

http://emcrit.org/preoxygenation

A well written blog post summarising the key features of a BVM from the Life in the Fast Lane team:

http://lifeinthefastlane.com/ccc/bag-mask/

This is a great (and entertaining!) video cast from Emergency Medicine colleagues in the States discussing and demonstrating techniques for optimal bag-valve-mask ventilation.

References

Wilmalasena Y, Burns B, Reid C, Ware S., Habig K. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Annals of Emergency Medicine. 2015; 65(4): 371-376.

Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine. 2012; 59(3): 165-175.

Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed Sequence Intubation: A Prospective Observational Study. Annals of Emergency Medicine. 2014; 65(4): 349-355.

Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the Emergency Department. The Journal of Emergency Medicine. 2010;

Grant S, Khan F, Keijzers G, Shirran M, Marneros L. Ventilator-assisted preoxygenation: protocol for combining non-invasive ventilation and apnoeic oxygenation using a portable ventilator. Emergency Medicine Australasia. 2016: 28(1); 67-72.

Von Goedecke A, Wenzel V, Hormann C, Voelckel WG, Wagner-Berger HG, Zecha-Stallinger A, Luger TJ, Keller C. Effects of face mask ventilation in apneic patients with a resuscitation ventilator in comparision with a bag-valve-mask. Journal of Emergency Medicine. 2006: 30(1); 63-67.

Semier MW, Janz DR, Lentz RJ, Matthews DT, Norman BC, Assad TR, Keriwala RD, Ferrell BA, Noto MJ, McKown AC, Kocurek EG, Warren MA, Huerta LE, Rice TW. Randomized trial of apneic oxygenation during endotracheal intubation of the critically ill. American Journal of Respiratory Critical Care Medicine. 2016; 193(3): 273-280. (FELLOW Trial)

How to cite this podcast:

Nutbeam T, Bosanko C. Oxygenation. PHEMCAST. 2016 [cite Date Accessed]. Available from: http://www.phemcast.co.uk

Episode 5: Amputation

Amputation

 

 

Welcome to PHEMCAST episode 5: Amputation

One of the things we never want to have to do, but need to be prepared for. Have a listen, consider your kit, your top-cover arrangements, and when and how you may need to get this done.

This podcast covers, which patients to consider, how to do it and discussion around consent, capacity and top-cover arrangements.

This podcast features interviews with Professor Sir Keith Porter and Caroline Leech, which we hope you will enjoy.

 

Which patients / scenarios:

  1. An immediate and real risk to the patient’s life due to a scene safety emergency.
  2. A deteriorating patient physically trapped by a limb when they will almost certainly die during the time taken to secure extrication
  3. A completely mutilated non-survivable limb retaining minimal attachment, which is delaying extrication and evacuation from the scene in a non-immediate life-threatening situation.
  4. The patient is dead and their limbs are blocking access to potentially live casualties.

 

Which kit:

  • CAT x 2
  • Scalpel
  • Gigli saw (and spare)
  • Arterial forceps x 4
  • Tuff Cut scissors
  • Appropriate dressing (e.g. Israeli combat bandage)

 

Preparation:

  • Sedation or anaesthesia
  • Brief team
  • Plan next phase

 

Stages of amputation process:

  • Apply an effective proximal tourniquet.
  • Amputate as distally as possible.
  • Perform a guillotine amputation.
  • Apply haemostats to large blood vessels.
  • Leave the tourniquet in situ.

(consider IV antibiotics if can be delivered as concurrent activity)

 

Please contribute to the blog below – specifically around top cover arrangements, decision making and individual competency around this procedure.

 

References:

Porter KM. Prehospital amputation. Emerg Med J. 2010 Dec 1;27(12):940–2.

Reid C, Clancy M. Life, limb and sight-saving procedures–the challenge of competence in the face of rarity. Emerg Med J. 2013 Feb 1;30(2):89–90. .

Porter K. Ketamine in prehospital care. Emerg Med J. 2004 May 1;21(3):351–

Brodie S, Hodgetts TJ, Ollerton J, McLeod J, Lambert P, Mahoney P. Tourniquet use in combat trauma: UK military experience. J R Army Med Corps. 2007 Dec 1;153(4):310–3.

Akporehwe NA, Wilkinson PR, Quibell R, Akporehwe KA. Ketamine: a misunderstood analgesic? BMJ. 2006 Jun 24;332(7556):1466.

McNicholas MJ, Robinson SJ, Polyzois I, Dunbar I, Payne AP, Forrest M. ‘Time critical’ rapid amputation using fire service hydraulic cutting equipment. Injury. 2011; 42: 1333-1335.

Episode 4: Chemical incidents

Chemical

We hope you enjoyed this PHEMCast. Please feedback your comments via the blog, twitter or email us on PHEMCAST@gmail.com.

The NARU video we mention in the podcast can be accessed here:

http://naru.org.uk/videos/ior-nhs/

And the paper we discuss is:

  • Chilcott RP. Managing mass casualties and decontamination. Environmental International. 2014; 72: 37-45.

This is the Step 1,2,3 tool described:

Screen Shot 2016-01-04 at 12.15.12

For more information on the toxidromes associated with various chemicals, biological agents and radiation sources have a look at this document (admittedly it’s a few years old but the content is still good, especially the flow chart which is pasted below):

http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340709/Chemical_biological_radiological_and_nuclear_incidents_management.pdf

Screen Shot 2016-01-04 at 12.11.00

What is an anti-muscarinic chemical?

  • Anti-muscarinic = blocking the muscarinic receptors, ie blocking the effect of acetylcholine, hence also called anti-cholinergic. Impacts on parasympathetic stimulation. Antimuscarinic effects include dilated pupils (leading to blurred vision), reduced secretion of saliva (hence dry mouth), sweat and digestive juices. Relaxation of smooth muscle causing urinary retention, ileus. Also tachycardia, confusion progressing to delirum/coma.
  • Nerve agents inhibit anticholinesterase therefore there is an excess of acetylcholine resulting in opposite features: diarrhoea, urination, miosis, increased bronchial secretions, bronchoconstriction, vomiting, lacrimation, salivation.

 

Always ahead of the curve… St Emlyns have recently published a blog post on this very topic! It’s great, so have a read:

http://stemlynsblog.org/cbrn-an-introduction/

 

Further Reading

  1. Monteith RG. Pearce LDR. Self-care Decontamination within a Chemical Exposure Mass-casualty Incident. Prehospital and Disaster Medicine. 2015; 30: 288-296.
  2. http://chemm.nlm.nih.gov/mmghome.htm
  3. Centers for Disease Control and Prevention. Chemical Suicides in Automobiles – Six States, 2006-2010. JAMA. 2001; 306(16): 1751-1753.
  4. http://www.msdmanuals.com/en-gb/professional/injuries;-poisoning/poisoning/general-principles-of-poisoning#v1118045
  5. https://www.england.nhs.uk/wp-content/uploads/2015/04/eprr-chemical-incidents.pdf
  6. JRCALC http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/chemical_biological_radiological_and_nuclear_incidents_2006.pdf

 

How to cite this podcast:

Nutbeam T, Bosanko C. Chemical Incidents. PHEMCAST. 2016 [cite Date Accessed]. Available from: http://www.phemcast.co.uk

 

 

Episode 3: Hyperoxia

Hyperoxia

 

Hello and welcome to our next episode – we hope you enjoy it. This episode concentrates on hyperoxia – the delivery of lots (often too much) oxygen and the harms it may cause our patients. We both had colds – many apologies for the blocked noses and many sniffs!

We hope you find it useful.

To follow: Dr Matt Thomas from the Great Western Air Ambulance discussing his groups work around reducing hyperoxia post-rosc.

Further reading:

  1.  https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/
  2. Cornet AD, Kooter AJ, Peters MJL, Smulders YM. The potential harm of oxygen therapy in medical emergencies. Crit Care. 2013 Apr 11;17(2):313.
  3. Rincon F, Kang J, Maltenfort M, Vibbert M, Urtecho J, Athar MK, et al. Association Between Hyperoxia and Mortality After Stroke. Crit Care Med. 2014 Feb;42(2):387–96.
  4. Stub D, Smith K, Bernard S, Bray J, Stephenson M, Cameron P, et al. A randomized controlled trial of oxygen therapy inacute myocardial infarction Air Verses Oxygen InmyocarDial infarction study (AVOID Study). American Heart Journal. Mosby, Inc; 2012 Mar 1;163(3):339–345.e1. 3.    Asfar P, Singer M, Radermacher P. Understanding the benefits and harms of oxygen therapy. Intensive Care Med. 2015 Jan 30.
  5. Calzia E, Asfar P, Hauser B, Matejovic M, Ballestra C, Radermacher P, et al. Hyperoxia may be beneficial. Crit Care Med. 2010 Oct;38:S559–68.
  6. Asfar P, Calzia E, Huber-Lang M, Ignatius A, Radermacher P. Hyperoxia during septic shock–Dr. Jekyll or Mr. Hyde? Shock. 2011 Nov 21;37(1):122–3.
  7. Cornet AD, Kooter AJ, Peters MJL, Smulders YM. The potential harm of oxygen therapy in medical emergencies. Crit Care. 2013 Apr 11;17(2):313.
  8. Ligtenberg JJM, Stolmeijer R, Broekema JJ, Maaten ter JC, Zijlstra JG. A little less saturation? Crit Care. 2013 Jun 12;17(3):439.

 

How to cite this podcast:

Nutbeam T, Bosanko C. Hyperoxia. PHEMCAST. 2015 [cite Date Accessed]. Available from: http://www.phemcast.co.uk

Episode 2: The Pelvic Binder

Pelvis-2

Sorry for the slight delay releasing our “October” podcast – but here it is (note how it is cunningly labelled Episode 2)! This month we are reviewing the evidence for the pelvic binder and discussing scenarios in which it should (and should not) be used.

As always, please get in touch with questions and comments, either via the blog, twitter or email phemcast@gmail.com

This is where the greater trochanters are:

greater trochanters

This is where a binder should sit on the pelvis – it commonly ends up higher, either in application or ‘rides up’ during transfer – keep an eye on it!

binder position

These are the different types of fracture pattern that can occur in a pelvic fracture: of course patients can suffer from multiple force vectors so may end up with any combination of these fracture types.

fracture types

Please click on this link below for our video on using a scoop to insert the pelvic binder…

As always… Get in touch!

References

  1. Scott I, Porter K, Laird C, Greaves I, Bloch M. The prehospital management of pelvic fractures: initial consensus statement. EMJ. 2013; 30(12): 1070-1072.
  2. Lee C, Porter K. The prehospital management of pelvic fractures. EMJ. 2007; 24: 130-133.
  3. Prasarn ML, Conrad B, Small J, Horodyski M, Rechtine GR. Comparison of circumferential pelvic sheeting versus the T-POD on unstable pelvic injuries: A cadaveric study of stability. Injury. 2013; 44: 1756-1759.
  4. Trebilcock H. Reducing overtriage and undertriage rates if pelvic fractures and unnecessary pelvic binder applications in major trauma patients. EMJ. 2015; 32(6): e17.
  5. DeAngelis NA, Wixted JJ, Drew J, Eskander MS, Eskander JP, French BG. Use of the trauma pelvic orthotic device (T-POD) for provisional stabilisation of anterior-posterior compression type pelvic fractures: A cadaveric study. Injury. 2008; 39: 903-906.
  6. Bottlang M, Krieg JC, Mohr M, Simpson TS, Madey SM. Emergent management of pelvic ring fractures with use of circumferential compression. The Journal of Bone & Joint Surgery. 2002; 84A (2): 43-47.
  7. Tan ECTH, van Stigt SFL, van Vugt AB. Effect of a new pelvic stabilizer (T-POD) on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures. Injury. 2010; 41(12): 1239-1243.
  8. Knops SP, Van Lieshout EMM, Spanjersberg WR, Patka P, Schipper IB. Randomised clinical trial comparing pressure characteristics of pelvic circumferential compression devices in healthy volunteers. Injury. 2011; 42(10): 1020-1026.
  9. Mason LW, Boyce DE, Pallister I. Catastrophic myonecrosis following circumferential pelvic binding after massive crush injury: A case report. Injury Extra. 2009: 84-86.
  10. Stewart M. BestBet: Pelvic circumferential compression devices for haemorrhage control: panacea or myth. EMJ. 2013; 30: 425-426.
  11. Croce MA, Magnotti LJ, Savage SA, Wood GW, Fabian TC. Emergent pelvic fixation in patients with exsanguinating pelvic fractures. Journal of American College of Surgeons. 2007; 204: 935-942.
  12. Knops SP, Schep NWL, Spoor CW, van Riel MPJM, Spanjersberg WR, Kleinrensink GJ, van Lieshout EMM, Patka P, Schipper IB. Comparison of three different pelvic circumferential compression devices: A biomechanical cadaver study. Journal of Bone & Joint Surgery. 2011; 93: 230-240.
  13. Knops SP, van Riel MPJM, Goossens RHM, Lieshout EMM, Patka P, Schipper IB. Measurements of the exerted pressure by pelvic circumferential compression devices. The Open Orthopaedics Journal. 2010; 4: 101-106.

How to cite this podcast:

Nutbeam T, Bosanko C. The Pelvic Binder. PHEMCAST. 2015 [cite Date Accessed]. Available from: http://www.phemcast.co.uk

Podcast: September 2015: The LMA

The LMA Phemcast

Here it is – our very first podcast, and guess what – it is on supraglottic airways!

This first episode reviews the history of the laryngeal mask airway and we discuss the relative benefits and risks of supraglottic airway devices. We’ve interviewed Dr Rob Moss, author of the Faculty of Prehospital Care (FPHC) Consensus Guidelines on pharmacologically assisted laryngeal mask (PALM) insertion. Click here for the link to the guideline.
We also met Professor Jonathan Benger and discuss the role of supraglottic devices in patients in cardiac arrest. Please have a look at the airways 2 trial website here.

References and resources:

  1. Benger JR, Voss S, Coates D, Greenwood R, Nolan J, Rawstorne S, et al. Randomised comparison of the effectiveness of the laryngeal mask airway supreme, i-gel and current practice in the initial airway management of prehospital cardiac arrest (REVIVE-Airways): a feasibility study research protocol. BMJ Open. 2013 Jan 31;3(2):e002467–7.
  2. Berlac P, Hyldmo PK, Kongstad P, Kurola J, Nakstad AR, Sandberg M. Pre-hospital airway management: guidelines from a task force from the Scandinavian Society for Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand. 2008 Jul 9;52(7):897–907.
  3. Bosch J, de Nooij J, de Visser M, Cannegieter SC, Terpstra NJ, Heringhaus C, et al. Prehospital use in emergency patients of a laryngeal mask airway by ambulance paramedics is a safe and effective alternative for endotracheal intubation. Emergency Medicine Journal. 2014 Aug 14;31(9):750–3.
  4. Cook T, Howes B. Supraglottic airway devices: recent advances. Continuing Education in Anaesthesia, Critical Care & Pain. 2011 Mar 15;11(2):56–61.
  5. Deakin CD, Clarke T, Nolan J, Zideman DA, Gwinnutt C, Moore F, et al. A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008. Emergency Medicine Journal. 2010 Mar 19;27(3):226–33.
  6. Deakin CD, Peters R, Tomlinson P, Cassidy M. Securing the prehospital airway: a comparison of laryngeal mask insertion and endotracheal intubation by UK paramedics. Emergency Medicine Journal. 2004 Dec 20;22(1):64–7.
  7. Gruber C, Nabecker S, Wohlfarth P, Ruetzler A, Roth D, Kimberger O, et al. Evaluation of airway management associated hands-off time during cardiopulmonary resuscitation: a randomised manikin follow-up study. Scand J Trauma Resusc Emerg Med. 2013;21:10.
  8. Hasegawa K, Hiraide A, Chang Y, Brown DFM. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA. 2013 Jan 16;309(3):257–66.
  9. Kajino K, Iwami T, Kitamura T, Daya M, Ong ME. Comparison of supraglottic airway versus endotracheal intubation for the pre-hospital treatment of out-of-hospital cardiac arrest. Crit Care. 2011.
  10. Mason AM. Prehospital Use of the Intubating Laryngeal Mask Airway in Patients with Severe Polytrauma: A Case Series. Case Reports in Medicine. 2009;2009(3):1–7.
  11. Middleton PM, Simpson PM, Thomas RE, Bendall JC. Higher insertion success with the i-gel® supraglottic airway in out-of-hospital cardiac arrest: A randomised controlled trial. Resuscitation. 2014 Jul;85(7):893–7.
  12. Moss R, Porter K, Greaves I, consensus group Faculty of Pre-Hospital Care. Pharmacologically assisted laryngeal mask insertion: a consensus statement. Emergency Medicine Journal. 2013 Dec;30(12):1073–5.
  13. Ostermayer DG, Gausche-Hill M. Supraglottic Airways: The History and Current State of Prehospital Airway Adjuncts. Prehosp Emerg Care. 2014 Jan;18(1):106–15.
  14. Ramachandran SK, Kumar AM. Supraglottic Airway Devices. Respiratory Care. 2014 Jun 2;59(6):920–32.
  15. Schmid M, Mang H, Ey K, Schüttler J. Prehospital airway management on rescue helicopters in the United Kingdom. Anaesthesia. 2009 Jun;64(6):625–31.
  16. Tanabe S, Ogawa T, Akahane M, Koike S, Horiguchi H, Yasunaga H, et al. Comparison of Neurological Outcome between Tracheal Intubation and Supraglottic Airway Device Insertion of Out-of-hospital Cardiac Arrest Patients: A Nationwide, Population-based, Observational Study. J Emerg Med. 2013 Feb;44(2):389–97.
  17. Wang HE, Szydlo D, Stouffer JA, Lin S, Carlson JN, Vaillancourt C, et al. Endotracheal intubation versus supraglottic airway insertion in out-of-hospital cardiac arrest. Resuscitation. 2012 Sep;83(9):1061–6.

How to cite this podcast:

Nutbeam T, Bosanko C. The LMA. PHEMCAST. 2015 [cite Date Accessed]. Available from: http://www.phemcast.co.uk